Tag: pituitary stalk

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Is It Justified to Sacrifice the Pituitary Stalk During Craniopharyngioma Surgery? A Systematic Review and Meta-Analysis

Neurosurgery 96:725–733, 2025

This systematic review and meta-analysis examined the impact of pituitary stalk sacrifice during craniopharyngioma surgery. It found that sacrificing the stalk significantly increases the risk of postoperative endocrine dysfunction without reducing tumor recurrence or progression, highlighting the importance of preserving the stalk when possible.

• Pituitary stalk sacrifice increases risk of endocrine dysfunction without reducing recurrence risk.

• Preservation of the pituitary stalk is recommended whenever possible.

• Fourteen studies with 2074 patients were included in the meta-analysis.

• Stalk sacrifice associated with higher endocrine dysfunction risk (OR = 6.69, P < .0001).

• No significant decrease in recurrence risk with stalk sacrifice (OR = 0.80, P = .13).

• Retrospective studies were included, no randomized trials.

• Endoscopic endonasal and transcranial approaches were evaluated.

• Molecular biology factors like β-catenin mutations affect recurrence risk.

• Confounding factors like age and preoperative endocrinopathy impact outcomes.

• Future prospective studies recommended to assess confounding factors.

• Stalk preservation linked to better outcomes in normal preoperative endocrine function.

• Radiation therapy recommended post-GTR for β-catenin positive cases to prevent progression.

• Stalk preservation does not increase recurrence/progression risk according to multiple studies.

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Effect of pituitary stalk preservation during craniopharyngioma removal on pituitary function, extent of resection, and recurrence: systematic review and meta-analysis

J Neurosurg 142:741–755, 2025

The meta-analysis evaluates the impact of pituitary stalk preservation during craniopharyngioma surgery on pituitary function, resection extent, and recurrence. Preservation reduces diabetes insipidus risk but may increase incomplete resection risk in pediatric patients. Results are cautious due to small study sizes and reporting biases.

• Pituitary stalk preservation reduces risk of postoperative diabetes insipidus (DI) and anterior pituitary dysfunction.

• Preservation shows no significant impact on tumor recurrence or extent of resection.

• Pediatric patients face higher risk of incomplete resection with stalk preservation.

• Meta-analysis included 33 studies with 2366 patients.

• Significant heterogeneity observed in DI and recurrence risk across studies.

• Stalk preservation benefits posterior pituitary function long-term, not anterior.

• High risk of bias in individual studies; findings should be interpreted cautiously.

• Subgroup analysis highlights higher recurrence risk in pediatric stalk preservation.

• Egger’s test indicates publication bias in DI analysis.

• Previous meta-analysis by Li et al. lacked age stratification and EEA cases.

• Authors recommend careful consideration of stalk preservation in pediatric cases.

• Lack of age-stratified data limits analysis and may increase bias.

• Study methods followed PRISMA guidelines, with data extracted from eligible studies

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Predictors of extent of resection and recurrence following endoscopic endonasal resection of craniopharyngioma

J Neurosurg 139:1235–1246, 2023

Craniopharyngioma is a benign but surgically challenging brain tumor. Controversies exist regarding its ideal treatment strategy, goals of surgery, efficacy of radiation, and the long-term outcomes of these decisions. The authors of this study performed a detailed analysis of factors predictive of the extent of resection and recurrence in large series of craniopharyngiomas removed via an endoscopic endonasal approach (EEA) with long-term follow-up.

METHODS From a prospective database of all EEAs done at Weill Cornell Medical College by the senior author from 2004 to 2022, a consecutive series of histologically proven craniopharyngiomas were identified. Gross-total resection (GTR) was generally the goal of surgery. Radiation was often given if GTR had not been achieved. The stalk was preserved if not infiltrated with tumor but was sacrificed to achieve GTR. Intentional subtotal resection (STR) was performed in select cases to avoid hypothalamic injury.

RESULTS Among the 111 identified cases were 88 adults and 23 children. Newly diagnosed cases comprised 58.6% of the series. GTR was attempted in 77.5% of the patients and among those cases was achieved in 89.5% of treatmentnaive tumors and 72.4% of recurrent tumors. An inability to achieve GTR was predicted by prior surgical treatment (OR 0.13, 95% CI 0.03–0.6, p = 0.009), tumor diameter ≥ 3.5 cm (OR 0.11, 95% CI 0.02–0.53, p = 0.006), and encasement of the optic nerve or a major artery (OR 0.11, 95% CI 0.01–0.8, p = 0.03). GTR with stalk preservation maintained some anterior pituitary function in 64.5% of cases and prevented diabetes insipidus in 25.8%. After a median follow-up of 51 months (IQR 17–80 months), the recurrence rate after GTR was 12.5% compared with 38.5% after non-GTR. The median recurrence-free survival was 5.5 years after STR, 8.3 years after near-total resection (≥ 98%), and not reached after GTR (p = 0.004, log-rank test). GTR was the strongest predictor of recurrence-free survival (OR 0.09, 95% CI 0.02–0.42, p = 0.002), whereas radiation did not show a statistically significant impact (OR 1.17, 95% CI 0.45–3.08). In GTR cases, the recurrence rate was higher if the stalk had been preserved (22.6%) as opposed to a sacrificed stalk (4.9%; OR 5.69, 95% CI 1.09–29.67).

CONCLUSIONS The study data show that GTR should be the goal of surgery in craniopharyngiomas if it can be achieved safely. Although stalk preservation can maintain some endocrine function, the risk of recurrence is higher in such cases. Radiation may not be as effective as previously reported.

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Optic nerve mobilization to enhance the exposure of the pituitary stalk during craniopharyngioma resection

optic-nerve-mobilization-to-enhance-the-exposure-of-the-pituitary-stalk-during-craniopharyngioma-resection

J Neurosurg 125:683–688, 2016

Preservation of the pituitary stalk and its vasculature is a key step in good postoperative endocrinological outcome in patients with craniopharyngiomas. In this article, the authors describe the surgical technique of medial optic nerve mobilization for better inspection and preservation of the pituitary stalk.

Methods This operative technique has been applied in 3 patients. Following tumor exposure via a frontolateral approach, the pituitary stalk could be seen partially hidden under the optic nerve and the optic chiasm. The subchiasmatic and opticocarotid spaces were narrow, and tumor dissection from the pituitary stalk under direct vision was not possible. The optic canal was therefore unroofed, the falciform ligament was incised, and the lateral part of the tuberculum sellae was drilled medial to the optic nerve. The optic nerve could be mobilized medially to widen the opticocarotid triangle, which enhanced visualization of and access to the pituitary stalk.

Results By using the optic nerve mobilization technique, the tumor could be removed completely, and the pituitary stalk and its vasculature were preserved in all patients. In 2 patients, vision improved after surgery, while in 1 patient it remained normal, as it was before surgery. The hormonal status remained normal after surgery in 2 patients. In the patient with preoperative hormonal deficiencies, improvement occurred early after surgery and hormonal levels were normal after 3 months. No approach-related complications occurred.

Conclusions This early experience shows that this technique is safe and could be used as a complementary step during microsurgery of craniopharyngiomas. It allows for tumor dissection from the pituitary stalk under direct vision. The pituitary stalk can thus be preserved without jeopardizing the optic nerve.

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Infundibulo-tuberal or not strictly intraventricular craniopharyngioma: evidence for a major topographical category

Acta Neurochir (2011) 153:2403–2426. DOI 10.1007/s00701-011-1149-4

This study investigates retrospectively the clinical, neuroradiological, pathological and surgical evidence verifying the infundibulo-tuberal topography for craniopharyngiomas (CPs). Infundibulo-tuberal CPs represent a surgical challenge due to their close anatomical relationships with the hypothalamus. An accurate definition of this topographical category is essential in order to prevent any undue injury to vital diencephalic centres.

Methods A systematic review of all scientific reports involving pathological, neuroradiological or surgical descriptions of either well-described individual cases or large series of CPs published in official journals and text books from 1892 to 2011 was carried out. A total of 1,232 documents providing pathological, surgical and/or neuroradiological evidence for the infundibulo-tuberal or hypothalamic location of CPs were finally analysed in this study.

Findings For a total of 3,571 CPs included in 67 pathological, surgical or neuroradiological series, 1,494 CPs (42%) were classified as infundibulo-tuberal lesions. This topography was proved in the autopsy of 122 nonoperated cases. The crucial morphological finding characterizing the tubero-infundibular topography was the replacement of the third ventricle floor by a lesion with a predominant intraventricular growth. This type of CP usually presents a circumferential band of tight adherence to the third ventricle floor remnants, formed by a functionless layer of rective gliosis of a variable thickness. After complete surgical removal of an infundibulo-tuberal CP, a wide defect or breach at the floor of the third ventricle is regularly observed both in the surgical field and on postoperative magnetic resonance imaging studies.

Conclusions Infundibulo-tuberal CPs represent a major topographical category of lesions with a primary subpial development at the floor of the third ventricle. These lesions expand within the hypothalamus itself and subsequently occupy the third ventricle; consequently, they can be classified as not strictly intraventricular CPs. A tight attachment to the hypothalamus and remnants of the third ventricle floor is the pathological landmark of infundibulotuberal CPs.

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Adult craniopharyngiomas: surgical results with a special focus on endocrinological outcomes and recurrence according to pituitary stalk preservation

DOI: 10.3171/2008.10.JNS0880

The aim of this study was to evaluate the results of surgical treatment of adult craniopharyngioma with a special focus on the endocrinological outcomes and tumor recurrence in cases of pituitary preservation.

Methods: Between 1993 and February 2008, 41 patients underwent 47 surgical procedures for craniopharyngioma. The male/female ratio was 26:15 and the median age was 45.8 years (range 17–65 years). The median follow-up period was 10.56 years (range 6.2–14.9 years). Patients presented with visual disturbance before 30 (63.8%) of 47 procedures and with endocrinological disturbance before 12 (26%) procedures. Surgery was performed via a subfrontal/pterional approach in 31 procedures (66%), bifrontal interhemispheric in 6 (12.8%), transcallosal/transventricular in 5 (10.6%), combined in 1 (2.1%), and transsphenoidal in 4 (8.5%). The tumor was totally removed in 36 procedures (76.6%), subtotally in 10 (21.3%), and partially in 1 (2.1%).

Results: Postoperatively, the rates of visual improvement and aggravation were 50 and 33.3%, respectively. Of 24 patients in whom the pituitary stalk was preserved, complete hormone replacement was needed in 14 (58.3%), partial replacement in 2 (8.3%), and no replacement in 8 (33.3%). The rate of tumor recurrence was 24.4%. The recurrence-free survival rate was significantly different between patients in whom complete tumor resection was accomplished and those in whom tumor resection was incomplete. Stalk preservation did not affect the recurrence-free survival rate. The morbidity and mortality rates were 8.5 and 2.1%, respectively.

Conclusions: The pituitary stalk must be preserved with maximal tumor resection whenever possible to increase the chance of intact anterior pituitary function being maintained. The results of the present study show that pituitary stalk preservation may not be related to increased recurrence rates.

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